High burden of co-morbidity and mortality among severely malnourished children admitted to outpatient therapeutic programme facilities in the conflict setting of Borno, Nigeria: a retrospective review.

OBJECTIVE: To present evidence on the burden and outcomes of co-morbidities among severely malnourished (SAM) children admitted to outpatient therapeutic programme (OTP) facilities in the conflict setting of Borno, Nigeria. DESIGN: Retrospective medical chart review. SETTING: Facility-based study.ParticipantsChildren aged 6-59 months with SAM enrolled in OTP between June and November 2016 whose medical records were analysed. Only pneumonia and diarrhoea were examined due to data limitations. Stata software was used for descriptive, multivariate and survival analyses. RESULTS: Records of 396 children with median age of 15 months were identified and analysed from the date of enrolment to exit from OTP. Mean length of stay in OTP was 61d, with co-infected SAM children having shorter stay (P=0·006). Of the total, 148 (37·4 %) had at least one co-morbidity (pneumonia or diarrhoea), of which thirty-nine (26·4 %) had both. Cumulative rate of mortality during follow-up time was 9·5 (95 % CI 6·0, 15·1) per 10 000 child-days; SAM children with co-morbidities were ten times more likely to die than those without (hazard ratio=10·2; 95 % CI 3·4, 31·0). In multivariable analysis, co-morbidity (P=0·01), oedema (P=0·003), dehydration (P=0·02) and weight on admission (P=0·01) were associated with mortality. Both recovery and defaulter rates (57·8 and 36·1 %, respectively) did not meet SPHERE standards. CONCLUSIONS: Children with SAM and co-morbidities are less likely to survive, presenting a significant barrier in improving child survival. The findings call for integrated OTP models that incorporate clinical algorithms and ensure prompt referral for SAM children with co-morbidity.

Effects of duration of injection drug use and age at first injection on HCV among IDU in Kabul, Afghanistan.

BACKGROUND: Hepatitis C virus (HCV) prevalence is high among injection drug users (IDUs) in Afghanistan. Duration of injection and young age at first injection are common risk factors for HCV in IDU populations. The association of HCV with these time factors was analyzed. METHODS: Socio-demographic and drug use behavior information were collected. Participants had rapid testing for HCV with recombinant immunoblot assay confirmation. Modeling of non-linear associations was performed using fractional polynomial logistic regression. RESULTS: Among 459 male IDUs, age at first injection had a constant HCV risk (odds ratio (OR): 1.01 per year; 95% confidence interval (CI): 0.98-1.03), while each additional year of injection drug use had a significantly increased risk (OR: 4.72 per year, 95% CI: 2.92-7.66). HCV risk increased significantly with each additional year of injecting drug use by groups of injectors: young (< or =22 years, OR: 1.97; 95% CI: 1.27-3.07), middle (23-28 years, OR: 1.76; 95% CI: 1.28-2.43) and older (> or =29 years, OR: 7.56; 95% CI: 3.15-18.14). CONCLUSION: The probability of HCV infection increased markedly by duration of injection drug use and varied according to age at first injection. Drug counseling and educational efforts should be directed to older drug users who have not yet initiated injecting and to young IDUs to avert infection and reduce risky drug use behaviors.

A cross-sectional assessment of utilization of addiction treatment among injection drug users in Kabul, Afghanistan.

The purpose of this study was to describe prior use of detoxification and addiction-treatment programs among injection drug users (IDUs) in Kabul, Afghanistan. From 2005-2006, IDUs (n = 464) recruited into this cross-sectional study completed an interviewer-administered questionnaire and whole blood rapid testing with fingerstick samples for HIV, syphilis, and hepatitis C antibody and B surface antigen testing. Participants were predominantly male (99.8%), Afghan (98.9%), and had little formal education. Correlates of detoxification and addiction treatment were identified with logistic regression. The majority (94.0%, n = 435) felt great/urgent need for treatment, of whom 56.3% (n = 245) reported inability to access treatment. Prior detoxification was associated with new needle use with each injection (AOR = 1.91, 95% CI: 1.12-3.26) and prior incarceration (AOR = 1.81, 95% CI: 1.04-3.13). The study's limitations are noted. Rapid scale-up and subsidy of needle and syringe programs and opioid agonist treatment is urgently needed in Kabul.

Social Mobilization and Community Engagement Central to the Ebola Response in West Africa: Lessons for Future Public Health Emergencies.

Following the World Health Organization (WHO) declaration of a Public Health Emergency of International Concern regarding the Ebola outbreak in West Africa in July 2014, UNICEF was asked to co-lead, in coordination with WHO and the ministries of health of affected countries, the communication and social mobilization component-which UNICEF refers to as communication for development (C4D)-of the Ebola response. For the first time in an emergency setting, C4D was formally incorporated into each country's national response, alongside more typical components such as supplies and logistics, surveillance, and clinical care. This article describes the lessons learned about social mobilization and community engagement in the emergency response to the Ebola outbreak, with a particular focus on UNICEF's C4D work in Guinea, Liberia, and Sierra Leone. The lessons emerged through an assessment conducted by UNICEF using 4 methods: a literature review of key documents, meeting reports, and other articles; structured discussions conducted in June 2015 and October 2015 with UNICEF and civil society experts; an electronic survey, launched in October and November 2015, with staff from government, the UN, or any partner organization who worked on Ebola (N = 53); and key informant interviews (N = 5). After triangulating the findings from all data sources, we distilled lessons under 7 major domains: (1) strategy and decentralization: develop a comprehensive C4D strategy with communities at the center and decentralized programming to facilitate flexibility and adaptation to the local context; (2) coordination: establish C4D leadership with the necessary authority to coordinate between partners and enforce use of standard operating procedures as a central coordination and quality assurance tool; (3) entering and engaging communities: invest in key communication channels (such as radio) and trusted local community members; (4) messaging: adapt messages and strategies continually as patterns of the epidemic change over time; (5) partnerships: invest in strategic partnerships with community, religious leaders, journalists, radio stations, and partner organizations; (6) capacity building: support a network of local and international professionals with capacity for C4D who can be deployed rapidly; (7) data and performance monitoring: establish clear C4D process and impact indicators and strive for real-time data analysis and rapid feedback to communities and authorities to inform decision making. Ultimately, communication, community engagement, and social mobilization need to be formally placed within the global humanitarian response architecture with proper funding to effectively support future public health emergencies, which are as much a social as a health phenomenon.

Drug use and harm reduction in Afghanistan.

Opium has been cultivated in Afghanistan since 1100 A.D., although production has steadily increased since 1979. Currently, Afghanistan produces three-quarters of the global opium supply, with injection drug use and HIV currently following the opium trade route through Central Asia. Although systematic studies are lacking, heroin use appears to be on the rise in Afghanistan. The purpose of this paper is to briefly provide historical background and current statistics for drug production and use in Afghanistan, to discuss the new government's policies towards problem drug use and available rehabilitation programs, and to assess Afghan harm reduction needs with consideration of regional trends.

Correlates of receptive and distributive needle sharing among injection drug users in Kabul, Afghanistan.

We describe receptive and distributive needle/syringe sharing among injection drug users (IDUs) in Kabul, Afghanistan. In this cross-sectional study, IDUs completed an interviewer-administered questionnaire. Logistic regression identified correlates of needle sharing in the last six months. Receptive and distributive sharing in the last six months were reported by 28.2% and 28.7% of participants, respectively, and were both independently associated with reported difficulty obtaining new syringes (Receptive sharing: AOR = 2.60, 95% CI: 1.66-4.06; Distributive: AOR = 1.56, 95% CI: 1.02-2.39). Receptive and distributive sharing are common among IDU in Kabul; scaling up availability of sterile, no-cost injecting equipment is urgently needed.

Association between expatriation and HIV awareness and knowledge among injecting drug users in Kabul, Afghanistan: A cross-sectional comparison of former refugees to those remaining during conflict.

BACKGROUND: Little is known about human immunodeficiency virus (HIV) awareness among Afghan injecting drug users (IDUs), many of whom initiated injecting as refugees. We explored whether differences in HIV awareness and knowledge exist between Afghan IDUs who were refugees compared to those never having left Afghanistan. METHODS: A convenience sample of IDUs in Kabul, Afghanistan was recruited into a cross-sectional study through street outreach over a one year period beginning in 2005. Participants completed an interviewer-administered questionnaire and underwent voluntary counseling and testing for HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibody. Differences in HIV awareness and specific HIV knowledge between IDU who lived outside the country in the last decade versus those who had not were assessed with logistic regression. RESULTS: Of 464 IDUs, 463 (99%) were male; median age and age at first injection were 29 and 25 years, respectively. Most (86.4%) had lived or worked outside the country in the past ten years. Awareness of HIV was reported by 46.1%; those having been outside the country in the last decade were significantly more likely to have heard of HIV (48.3% vs. 31.7%; OR = 2.00, 95% CI: 1.14 - 3.53). However, of those aware of HIV, only 38.3% could name three correct transmission routes; specific HIV knowledge was not significantly associated with residence outside the country. CONCLUSION: Accurate HIV knowledge among Afghan IDUs is low, though former refugees had greater HIV awareness. Reported high-risk injecting behavior was not significantly different between IDU that were refugees and those that did not leave the country, indicating that all Afghan IDU should receive targeted prevention programming.

HIV, hepatitis C, and hepatitis B infections and associated risk behavior in injection drug users, Kabul, Afghanistan.

Limited prevalence data for HIV, hepatitis B surface antigen (HBsAg), and hepatitis C virus (HCV) exist for Afghanistan. We studied a cross-sectional sample of adult injection drug users (IDUs) in Kabul, Afghanistan, from June 2005 through June 2006. Study participants completed interviewer-administered questionnaires and underwent testing for HIV, antibody to HCV, and HBsAg. Overall prevalences of HIV, HCV, and HBsAg were 3.0% (95% confidence interval [CI] 1.7%-5.1%), 36.6% (95% CI 32.2%-41.0%), and 6.5% (95% CI 4.2%-8.7%), respectively (N = 464). Among male IDUs (n = 463), risky behavior, including sharing syringes (50.4%), paying women for sex (76.2%), and having sex with men or boys (28.3%), were common. Needle sharing, injecting for > or = 3 years, and receiving injections from nonmedical providers were independently associated with increased risk for HCV infection. The high prevalence of risky behavior indicate that Kabul is at risk for an HIV epidemic. Scale-up of harm-reducing interventions is urgently needed.